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9255517888 Line 10•IR:51 a.m. 10-27-2008 3/11 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 10# SEERIC UEST# <br /> SERVICE STATION r�rrso 0 36 3 JK17961 <br /> OWNER I OPERATOR <br /> BP West Coast Products LLC CHECK It BILLINGAODRESS <br /> FACILITY NAME ARCO 6080 <br /> SITE ADDRESS 85 E LOUISE AVE LATHROP 95330 <br /> Street Number Dlredlon e ecity Zlo Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6747 6747 Sierra Court,Suite J <br /> Street Number stmo Name <br /> CITY STATE ZIP <br /> Dublin CA 94568 <br /> PHONE#1 ExT• APN# 7 ` LAND USE APPLICATION# <br /> ( 925 ) 551-7555 �S" �-tP�—((C <br /> PHONE 02 Exr• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR LIDDY MCKENZIE CHECK If BILLINGADDRE00 <br /> BUSINESS NAIVE GettlerRyan Inc. PHONE#925 551-7555 EXT <br /> HOME or MAILING ADDRESS FAX <br /> 6747 6747 Sierra Court,Suite J ( 925 ) SSI-7888 <br /> CITY Dublin STATE CA zip 94568 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this applicatioVaTn�dtha he wor tobe performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE ala <br /> APPLICANT'S SIGNATURE: DATE: Z v� <br /> PROPERTY/BUSINESS OWNER❑ OPERAT / GER OTHER AUTHORIZED AGENT V Agentfor Owner <br /> IfAPPL/G1NT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENvIRoNMENfAL HEALTH DEPARTMENT as soon as it is available and at the same ki it is <br /> PA <br /> provided to me or my representative. YM�i <br /> TYPE OF SERmE REQUESTED: UST RETROFIT RE <br /> COMMENTS: t111�+ <br /> o C'T 2 I L <br /> REPLACE A POSITION SENSITIVE SENSOR(P/N 794380-323) ON PIPING SUMP <br /> L9(VAPOR POT) SAN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTME <br /> ACCEPTED BY: C I v I t EMPLOYEE M Li 3 z ( DATE: (v Ltd/ <br /> ASSIGNED TO: 1 ,2 EMPLOYEE#: S[.,y 2 DATE: I ?-j O <br /> Date Service Completed (if already completed): SEtmCE CODE: j n PIE: <br /> Fee Amount: t S . c_J Amount Paid \ S til) I <br /> Payment Date L-,A I U <br /> Payment Type C A Invoice X C�peClt� �1 Received By: <br /> EHD 48-02-025 ! SR FORM(Golden Rod) <br /> REVISED 11/17!2003 <br />